During the summer of 2010, Emergency Department (ED) Case Manager Margaret McDonagh Gallagher, RN, BSN, CCM, noticed that a certain man was becoming a bit of a regular in the ED, often making multiple visits per week.
Upon further investigation, McDonagh Gallagher and the ED staff were shocked to discover that the man had been seen in the ED no less than 79 times from January through July, 2010, in addition to more than 70 ED visits at other area hospitals. And he wasn’t the only one with multiple trips to the ED in a short period of time – there were many, many more.
A July, 2010 study in Annals of Emergency Medicine found that “frequent ED users,” defined as people who make four or more visits per year, make up over 21% of all ED visits, despite accounting for only 4.5% to 8% of all ED patients. Frequent ED users are sicker than most patients, require more medical interventions and are at a greater risk for hospitalization. Typically, they have public insurance and are heavy users of other parts of the health care system, in addition to the ED.
Often times, barriers like homelessness, lack of social support, mental illness, and drug or alcohol addiction precludes compliance with care plans. As a result, they often turn to the ED for treatment of their conditions. In the new era of heath care reform, reducing medical costs and promoting wellness has been identified as a primary goal. It was clear to McDonagh Gallagher and her colleagues that something needed to be done.
Helping people help themselves
The ED staff realized that most frequent ED users do actually need to be in the ED. The key to solving the problem was developing a formal system for determining each individual’s reason for requiring an ED visit. So they assembled multiple disciplines from the Medical Center, with the goal of creating a more efficient health care delivery system for the homeless population and any others who require social support to stay healthy.
The result was the Frequent Emergency Department Seekers (FEDS), a group of physicians, nurses, social workers, case managers and risk managers, that evaluates the needs of patients who frequently use the ED for their primary care, patients who are frequently in the ED due to substance abuse and patients who have been unable to get the follow-up care they need and find themselves seeking emergency care as a result.
“If a person is intoxicated in the ED at 3 am, dismissing them as an alcoholic is not going to solve the problem,” said Assistant Chief of the Department of Emergency Medicine Matthew B. Mostofi, DO. “You need to start by treating these patients as people and that is what the FEDS group is doing.”
Spearheaded by McDonagh Gallagher, Mostofi and Emergency Department Social Worker Annalisa Van Kirk, JD, LCSW, the FEDS team’s goal is to identify patients with multiple ED visits and intervene in the cycle, offer alternatives to frequent emergency care and use individualized case management to decrease ED utilization. The FEDS group compiles and maintains a list of frequent ED visitors, then engages them upon their next visit.
“Sometimes it is as simple as helping to get someone a State ID or birth certificate, so they can obtain housing or basic services and resources,” said Mostofi. “Once people have those things, social services are much more accessible.”
Growth and expansion
The formalized program has grown exponentially since it began in August 2010. FEDS has since been adapted by four other academic medical centers in Boston and has expanded internally to involve outpatient clinics and inpatient units. As the program took shape and began to show results, important relationships were established, including critical collaborations with Boston Health Care for the Homeless Program (BHCHP), the Boston Public Health Commission, the Massachusetts Health Association and the Department of Public Health.
Now, the FEDS team has the connections and resources to better utilize care options for patients, by quickly and seamlessly transferring a patient to BHCHP’s 104-bed medical respite Barbara McInnis House, coordinating a court detox, reestablishing a family connection or arranging for hospice care. In addition, a BHCHP staff nurse comes to Tufts Medical Center twice per week to meet with homeless patients; Barbara McInnis House has access to Tufts Medical Center physicians, if needed.
“What I appreciate most about our relationship with the Tufts Medical Center FEDS staff, is how deeply they care for our vulnerable patients,” said Sarah Ciambrone, Director of the Barbara McInnis House. “Since the Tufts Medical Center staff is so compassionate, it makes this challenging work we do together that much easier.”
This past year, BHCHP asked Tufts Medical Center to be their partner facility for a national Centers for Medicare & Medicaid Services (CMS) Health Care Innovation Grant. Only 10 cities across the country are involved and Tufts Medical Center is the only hospital in Boston that was selected to participate. The goal of the three-year grant is to decrease ED utilization and its related costs, by helping people to improve their own personal health. The early stages of the initiative have been quite successful; BHCHP hired community health care worker Diane Simmons, to help build a group of 25 ED seekers and help them address their medical, mental and social needs.
Much accomplished, much more to be done
Now in its third year of operation, the FEDS program has helped improve the lives of more than 500 frequent ED users since its inception. The program even has allowed the ED to more easily help homeless people who are not frequent ED users. In the future, McDonagh Gallagher hopes to develop the FEDS program for GMA, institute quarterly meetings with other hospital EDs to better coordinate action plans, and ultimately reduce Boston’s 6,600-person homeless count. “People may often give up on themselves, but they are not hopeless,” said McDonagh Gallagher. “Sometimes all they need is someone else to have faith in them and go to bat for them.”
“We really do care about the patients who come here,” said Mostofi. “We really are interested in their well-being and their big picture. We focus on encouraging good health, not just curing a disease – that is the whole point.”
As for the man whose frequent ED-seeking sparked the launch of the FEDS program? He was homeless and a substance abuser, so FEDS intervened and obtained a court order detox, which enabled him to receive multiple supportive services. Eventually, he was able to secure his own housing and became reacquainted with his family. Today, he holds a steady job selling shoes at a local shoe store.
“The success stories are living proof that each of us can really make a difference in people’s lives,” said McDonagh Gallagher. “Some days you go home exhausted, but the whole experience is extremely rewarding. It just goes to show that with the right support, people are able to change.”